Case Studies

Life can change in an instant: Thalia’s story

Thalia had been suffering headaches and blurred vision for a couple of weeks and without warning, one morning, she fell to the floor. Her husband rushed her to hospital.

She’d been diagnosed with a brain tumour, the size of a golf ball. She was taken to emergency and underwent immediate cranial brain surgery; the tumour was putting pressure on her brain and without the surgery, she would’ve died.

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When Thalia was out of danger, Adam, her adviser, was one of the first persons she spoke with and he reassured her that financially everything would be taken care of, as there was comprehensive insurance in place, including trauma cover.

Reassured, Thalia could focus on her recovery, without financial stress. Her operation was a success and the tumour was fortunately found to be benign.

The twist

Unfortunately, the trauma insurance policy she held, did not provide immediate payment for the diagnosis of a benign cranial brain tumour, only for the diagnosis of a malignant cranial brain tumour, which meant she wasn’t covered for what she thought she was.

How could this be? Didn’t Thalia suffer a major trauma? Hadn’t she undergone major evasive life-saving surgery?

Her policy then resorted to an alternative definition for a benign brain tumour. This definition stated that after 6 weeks post operative surgery, where Thalia had lost more than 25% of her daily ability to live, a claim would be payable. However, Thalia’s medical report stated that she had suffered impairment of 12%. The insurer was therefore not obliged to pay and consequently the claim was declined.

Consider this:

Do you know and understand exactly what your insurance policies cover?

Have you only looked at the cost of your policies or have you sought specialist advice about what you actually need?

The outcome

Luckily for Thalia, Adam went in hard to bat for her – for months on end he pleaded her case and explored every avenue for appeal. Finally after much research and discussion with the insurer, under the ‘issue of intent’ or intended purpose of cover, Adam convinced the insurance company that the intention was always to pay the claim, simply that Thalia had fallen between the cracks and missed out on a technicality.

In the end the insurer agreed and some two years later the claim was finally paid and the promise fulfilled!

The insurer to their credit, changed their definition of ‘trauma’ to capture future situations and revisited other instances where similar claims had been declined – it reversed those decisions.

View Thalia’s video interview

Read about Thalia’s emotional journey in her own words

My story…By Thalia

I first approached Adam with respect to personal insurance in May 2006. My husband, John, and I were looking at Income Protection insurance in the event something happened to him. Adam quickly pointed out to us that I was not working and so therefore I had no coverage for myself through my superannuation fund. We took out a minimal policy that gave me a basic coverage for Life, Permanent Disability and Trauma.

I first began to feel unwell in December 2008. I noticed I started to feel light headed and ever so slightly off balance. I put it down to exhaustion with a busy Term 4 with the kids at school and the lead up to Christmas which had us having 6 family members coming to stay. January, too, was a busy month with school holidays and friends coming from interstate. I figured I was just tired and hot. In hindsight I realise I should have done something back then as I could barely put washing on the line by now, as looking up to place the pegs made me feel dizzy and very tired.

Then one morning in February 2009 I got out of bed and slammed straight into the floor. I had absolutely no balance, no sense of which way was up. I crawled back into bed. John took me to the doctor that morning and I was advised my symptoms were due to an inner ear virus and I was likely to feel this way for the next 2 weeks. I worsened progressively through the day, unable to eat or drink and the slightest movement causing me to vomit. That evening an ambulance took me to hospital and again I was given the same diagnosis, an inner ear virus and this would last for around 2 weeks.

And so it was. It was like being seasick for 2 weeks straight. I crawled to the bathroom when I had to, the rest of the time I lay motionless in bed as turning my head, or worse, rolling over, sent waves of nausea through me. Fortunately John’s mother came across from Canberra to help, as with 2 children (aged 7 & 4) we would not have coped.
After 2 weeks with no abatement of symptoms John took me back to the doctor. We were advised to wait a few more days as he was reluctant to prescribe steroids and there really was nothing else that would help. One week later I was given those steroids and thing improved significantly. Within 3 days I could manoeuvre gently around the house and I started to eat again. Things got much better after that but the dizziness never really went away.

In June I started to see a Vestibular Physiotherapist to help me with the dizziness. He gave me a series of exercises to do each day but stressed the importance of having a CT Scan.

On 23rd July 2009 I had such a scan. My scan was at lunchtime. That afternoon I was sitting at the playground having collected my children from school when I received a call from the Radiologists Office. I was advised they had contacted my doctor and that I was to come past and pick up my scans immediately and go straight to the GP. I was told there was no need to call the doctor as he would be expecting me. Dr B advised me the radiologist believed I had what was called an ‘ependymoma’, a benign brain tumour in the 4th ventricle. I would need surgery and reasonably soon as the tumour was very large. Within a few hours I was back at the radiologist having an MRI ready for the neurosurgeon on Monday morning. On the way home we stopped at Hungry Jacks for dinner trying to make things special for my son, it was his 8th birthday.

Over the weekend we told family and friends our news. It was at this time we told Adam of my diagnosis and he advised he would begin proceedings to lodge a claim for the trauma insurance.

On Monday I met the neurosurgeon, Dr K. It was then that the gravity of the situation became most apparent to me. Apart from my ongoing dizziness, I had presented with no other neurological symptoms. I had no headaches, I could track with my eyes, touch my nose and walk in a straight line. It was this lack of symptoms which had allowed the tumour to go unnoticed for so long.

Dr K advised this lack of symptoms was most likely due to the tumour having likely been there and growing for several years which had allowed my body and brain to adjust. It had now grown to the point where it had almost completely filled my 4th ventricle and was pushing back on the cerebellum causing the dizziness to occur. It was 3.7cm in diameter and Dr K could not believe the brain fluid was still managing to get through and I technically should not have been able to walk. I was then taken through the surgical process and made aware of possible complications.

After shaving the back of my head, a drill would be used to grind away the back of my skull leaving an opening around the size of a golf ball. With all the muscles in this part of the body there would be no need to replace this section of the skull as the muscles would grow over and protect the back of my head. Dr K would then part my cerebellum and access the tumour that way. It would be at this point he would ascertain where the tumour was attached and its removal would begin. It was not possible to determine where the tumour was connected with the MRI. This was because the tumour was so large, it pushed up against several points so determining its origin was not possible until surgery. Worst case scenario was that it would be attached to my brain stem. This would make surgery even more complicated as complete removal would be extremely difficult without possibly causing severe side effects.

As my brain and body had adjusted to the pressure the tumour caused, its removal would in turn mean readjustment back again. Common side effects would be further dizziness and imbalance and also highly likely was double vision, which would be the result of disturbing the cerebellum. I was also warned of the possibility of stroke and paralysis, particularly if the tumour was indeed attached to the brain stem. Dr K advised though, that while these side effects were frightening and possibly severe, if I did not go through with the surgery the tumour would keep growing and it would kill me probably within 4 to 6 weeks. We scheduled surgery for August 12.

Adam was brought up to speed with the current state of my health. He proceeded with my claim however was advised by the Insurer that as my tumour was most likely benign, an assessment of my condition would need to be made post surgery as I needed to demonstrate a 25% deficiency to meet their conditions.

The surgery went extremely well. It was an 8 hour marathon with the worst case coming to fruition, with the tumour being attached to my brain stem. Dr K was however, still able to remove all of the tumour without me experiencing any of the more severe side effects of which I had been warned. I was in hospital and rehab for 2 weeks before returning home.
The side effects I did experience were just as predicted. I had dizziness and balance problems with the most significant being double vision. Recovery was slow but by 6 weeks and more noticeably at 3 months I made significant improvements.

The Insurance company made contact with my doctors for advice with regards to my state of health. The final conclusion was that I had not suffered sufficient deficiencies to meet the definition of a Benign Intracranial Tumour and so in April 2010 my claim was finalised and denied.

We moved on and let it go, Adam however, did not. In the middle of 2011 Adam presented me with a letter. Without my knowledge Adam had persisted with the Insurance company in relation to the intent of the Trauma cover of their policy. This letter advised that due to Adam’s extensive discussions with them with regards to my claim, a review was undertaken of their critical illness definition regarding Benign Intracranial Tumour and that this would be improved in future.

My own claim had therefore been reviewed and was now accepted. Full trauma benefit was now paid. It was July 23, my son’s 10th birthday and 2 years exactly to the day I was diagnosed.

In October 2011 I had a follow up MRI. There was no evidence of my tumour returning. While unable to guarantee it, Dr K advised at this point he thought it highly unlikely my tumour would ever return.

It really doesn’t get much better than that.

The heart of the matter

A whole lot of stress could’ve been avoided if the right insurance policy had been chosen for Thalia in the first place. However having someone like Adam, her adviser, who cared, made all the difference in the end.

Conflict and distress in a partnership: The story of Peter, Josh and Jack

Three business partners, Peter, Josh and Jack, sought our advice to implement a business succession plan. However, they were reluctant to work through and discuss details of their current situation and an analysis of any gaps of what they may need in the future.

No agreements of any sort were taken up or implemented, in particular, Josh brushed aside the issue of inadequate insurance and asked only for a loan protection portfolio which was put in place to cover obligations to the bank, based on equity splits between the partners. In fact, Josh was disinterested in insurance.

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We believed his insurance was inadequate for he had two young children to think of. Against our advice, he refused to have an additional policy on his life. He insisted that the existing insurance cover on his life was all he wanted and that it should be owned by the business and if anything happened to him, the claim should be paid into the business for commercial purposes.

The twist

Unfortunately Josh faced enormous personal and financial stress. The business situation took a nosedive as Josh’s emotional and physical health issues came to a critical point. He went into cardiac arrest and whilst on the road to recovery, he suffered severe depression and had to undergo a heavy treatment regime. Eventually Josh exited the business. When it was time to make an insurance claim, Josh denied that he had agreed to have his insurance owned by the company and threatened not to sign the claim forms, unless his partners split the claim pay-out with him.

The remaining business partners, Jack and Peter were furious and disillusioned. Their creditor – the bank – lost confidence and ruthlessly called a total loan recall. It cost the partners an additional $50,000 just to restructure their funding. Most of the money from the claim pay-out would go towards meeting this cost, leaving the business under enormous financial strain.

Consider this:

Does your adviser have the expertise to address your real business needs, to protect you, your family and your business against adverse circumstances?

Would your adviser manage the claims process on your behalf and help achieve a fair outcome for you?

The outcome

Their adviser had to guide the partners through a complex maze of policy definitions, medical reports, legal agreements and claims processes. More importantly, he was reassuring and reliable. He liaised with the insurance company to ensure they understood the circumstances and the claim was paid.

The heart of the matter

If there was ever conflict in the partnership, any agreements and protection you put in place today will have a profound impact on the outcome. Choose an adviser who is thorough and can guide you towards addressing your real needs and manage the claims process for you.